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New Customer Form

Name*
First Last
Email*
Enter Email Confirm Email
Billing Information
Business Name:*
A/P Contact:*
First Last
Bill To Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
A/P E-mail:*
A/P E-mail 2:
Is it okay to send Invoices to this e-mail address?*
- Yes
- No
Send Invoices To (E-mail Address):*
Separate multiple e-mail addresses with a ;
Are you setup to make payments via EFT/ACH?*
Electronic Funds Transfer/Automated Clearing House
- Yes
- No
Phone:*
Fax:
Notes:
Additional Information:
Will you be paying with a credit card?*
Your security is important to us. If you would like to pay with a credit card, we would be happy to take your information over the phone. Please call us at 317-776-6700
- Yes
- No
Tax Exempt?*
- Yes (please attach existing form)
- No
Tax Exempt Certificate:*
Do you have credit references you would like to submit?*
** Please note that we will not be able to approve Net Terms until references are provided. **
- Yes
- No
Attach References:*
Accepted file types: doc, docx, pdf, jpg, png, xls, xlsx.
Note:

Please do not navigate away from the page until you receive confirmation that your form was received. Thanks!

Contact Information

Email: sales@emptechgroup.com
Corporate Headquarters
17450 Tiller Ct, Westfield, IN 46074
Phone: (317) 776-6700 Fax: (317) 219-0535

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